Whine or win: How retail clinics will affect pediatricians

I noticed the headlines rolling in about the AAP updated policy statement regarding retail based clinics. The one above particularly caught my eye. Something about the tacking on of “again” caught my attention. It came across to me like we (pediatricians) were perceived to be saying something that was unnecessary, maybe even that we were just complaining.

Throughout the day, I monitored my Twitter feed and read some articles discussing the issue. Fortunately, I didn’t see a whole lot to confirm my (perhaps defensive) concern that we would be perceived as whining about the emergence of urgent and retail clinics.

But, the guideline and the response from the retail clinics got me thinking. Currently we seem to be doing okay in the public perception but how much longer does that hold up? Are our statements going to forever be met with an understanding or is there eventually going to be backlash about our perceived inflexibility.

There are many things that parents want in medical care for their children but I believe this debate boils down to 2 main issues: quality and convenience.

Quality

Pediatricians claim, in the policy, that retail based clinics create a decrease in quality of care for the following reasons:

fragmentation of care

provision of episodic care to children with special health care needs and chronic disease

lack of access to and maintenance of a complete, accessible, central health record that contains all pertinent patient information

the use of tests for the purposes of diagnosis without proper follow-up

possible public health issues that could occur when patients with contagious diseases are in a commercial, retail environment with little or no isolation (eg, fevers, rashes, mumps, measles, strep throat, etc.)

I do believe these are concerns that do need to be addressed by the urgent care and retail people. I have written about many of these previously: My Questions for Urgent Care Clinics.

The AAP policy statement goes on to make recommendations for principles with retail clinics (my thoughts italicized):

Supporting the medical home model: Retail- based clinics (RBCs) should support the medical home model by referring the patient back to the pediatrician or other primary care physician for all future care. (Is this realistic? They might even say that they will but will we eventually tell our patients that they should have just used the retail clinic for this complaint because it was simple? This won’t happen and I don’t know why we’d expect them to refer back to us either.)

Communication: The AAP recommends that RBCs promptly communicate with the patient’s pediatrician or other primary care physician within 24 hours of the visit. (This seems logical and important.)

Using evidence-based medicine: The AAP recommends that all those providing care to children follow all AAP clinical guidelines as well as those guidelines developed by other medical organizations that have the support and endorsement of the AAP. (Again, a reasonable and critical expectation.)

Contagious diseases: By providing medical care to individuals in a retail-based setting, RBCs must take the necessary precautions to prevent the spread of contagious diseases. (While many pediatricians do this, it is not universal and we need to do a better job of providing well and sick waiting rooms.)

Many of these concerns are addressed in the quote from the article:

The Convenient Care Association, a Philadelphia-based retail clinic association, took exception to the AAP’s claims about its members’ work.

“Retail clinics work closely with local physicians and pediatricians. They all use electronic health records (EHR) and actively encourage the sharing of visit records with a patient’s family physicians and pediatricians in order to facilitate continuity of care,” Tine Hansen-Turton, JD, the association’s executive director, said in a statement. “Additionally, the industry is very focused on quality care, and EHRs are also used in clinics to monitor evidence-based practice performance.”

Whether or not you agree with the assessment, they do provide an answer to many of the concerns that the AAP has raised.

Convenience

The second major issue I see arising as a result of the conversation is about convenience.

Let’s imagine that the retail clinics drafted a policy statement that addressed their concerns regarding care at pediatrician’s offices. Some of their concerns might go something like this:

lack of same day illness appointments creates unnecessary overnight suffering for parents and children

minor complaints should be seen by mid-level providers and escalated as necessary to the physician

parents’ schedules are malleable and need the flexibility of walk-in appointments

parents need the ability to have their children seen outside of their typical working hours to avoid lost income

These are some of the benefits of convenience that a retail clinic provides that many of us currently do not or we meet it in some trivial way that does not provide a real solution for families.

Don’t get me wrong, we have come a long way. Improving the patient/parent experience has always been a focus of pediatrics and will continue to be for years to come. But, there is some reason that our patients are using these clinics (and why we have to issue statements about them) and I would guess that for the most part it’s a convenience issue.

So, we’re still missing the boat (and an opportunity) somewhere.

The race is on

The way I see it, the race is on. One of two things are going to happen.

Retail clinics are going to figure out solution to our perception of their decreased quality of care and the public will know about it. Consider this quote from Tine Hansen-Turton, JD: “Retail clinics work closely with local physicians and pediatricians. They all use electronic health records (EHR) and actively encourage the sharing of visit records with a patient’s family physicians and pediatricians in order to facilitate continuity of care.” It tells me that they are already far along in their thinking and ready to make strides to improve their quality of care. They can’t afford to stop trying because it means their future success or failure.

Pediatric offices are going to figure out a way to meet the demand for patient convenience that is currently being met by the retail based and urgent care clinics. We need to make ourselves agile enough to meet the demands of convenience as they arise in the future. We can’t afford to stop trying because it means our future success or failure.

Whine or win: How retail clinics will affect pediatricians 7 comments

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http://onhealthtech.blogspot.com Margalit Gur-Arie

This is priceless: the “Convenient Care Association”…..
The AAP issuing guidelines to the RBCs is a bit humorous too. Anyway, the RBCs will figure out a solution: they will become medical homes, and it won’t take much to convince the public that an EMR with evidence-based protocols is as good, if not better than a doctor, particularly since that’s all the insurer is going to pay for, and that’s what the government is essentially saying as well. Perhaps the AAP should issue a different type of guidelines…..

Stewart Segal

Did it ever dawn on you that, by sending you copies of their EMR notes, the NP or PA-C in your local retail clinic is handing you, the physician, the legal responsibility for the care they deliver? Do you follow up on every one of their interactions? Do you document that you recieved their note, agree with their plan and call the patient to follow up to check on them?
If you do not follow up and something goes wrong, are you not liable? I think you are. I think that your local retail clinic puts you in the role of a supervising doc. Your ofice is burdened with the expense of proper follow up for which you are not reimbursed! Clever?
Putting all of that aside, do we really think that treating kids in a store front that sells cigarrettes and alcohol is appropiate? I think that relays a horrible message!!

NPPCP

In my opinion that is not a good example. Same applies when you send them to the ER or a specialist. Any follow up your patient gets requires you to follow up. It’s just in this case, some physicians don’t like it. Not sure why it’s win or whine. How about “get along” and be thankful for each other. Patients and most others see it as a “win win”

Justin Smith

I agree with you that being located in stores that sell alcohol and cigarettes (not to mention junk food and sodas) create a significant conflict of interest for retail clinics. CVS is taking steps to address this by pulling cigarettes and I think they will continue to make other changes to address many of the concerns addressed in the AAP guidelines. I guess I’m not sure what the purpose of the guidelines is: an encouragement to RBCs to make changes that we see fit or a message to parents to try and avoid them? Both?

Justin Smith

I think to some degree you are right…being available with comparable hours is critical. I have also had instances (especially during a busy winter) where patients have used urgent/retail during the day time because the next available appointment in my office was the afternoon or later in the day. I’m wondering if there’s some component of the “walk-in” piece that we need to address as well.

NPPCP

That is an integral part of the “much touted” PCMH. Later hours and weekend hours. If you want that business, you will have to stay up later Justin. In my private NP clinic, we do. The patients (including lots of peds) are always there.

NPPCP

I agree with Jason. Parents love pediatricians. It’s just that the RBCs are a little more innovative than most of the peds and have a larger workeforce to rotate through. All great points except the “stick it to them” comment. Didn’t add anything to the conversation in my opinion.